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.�' ° <br /> STATE OF CALIFORNIA � ,•• `°i <br /> STATE WATER RESOURCES CONTROL BOARD ;' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B w ° <br /> vo <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM �""�""��. <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED O / <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> L TANK DESCRIPTION COMPLETE ALL ITEMS—SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.i0-3 B. MANUFACTURED BY: N 4✓/V <br /> C. DATE INSTALLED(MO/DAY/YEAR) UNKIY D. TANK CAPACITY IN GALLONS: '500 <br /> ILTANKCONTENTS IFA-11S MARKED.COMPLETE ITEM C. <br /> 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ 1A REGULAR 3 DIESEL <br /> A. UNLEADED ❑ e AVIATION GAS <br /> F--] 2 PETROLEUM ❑ SO EMPTY 1 PRODUCT E—] 1b PREMIUM 4 OASAHOL ❑ 7 METHANOL <br /> UNLEADED ❑ 5 JETFUEL <br /> ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D.BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.is <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX <br /> A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER <br /> 8. TANK ® 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP <br /> (PllmuyTMk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 96 UNKNOWN ❑ as OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IFAPPLICABLE <br /> A. SYSTEM TYPE AG 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION AIZ 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U S ALUMINUM A U 6 CONCRETE A U 7 STEEL W(COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION [ MONITORING <br /> 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ O INTERSTITIAL 99 OTHER <br /> [1] <br /> V.TANK LEAK DETECTION <br /> [N�L CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> TESTING ❑ 7 INTERSTITIAL MONITORING ® 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED MO/DAY/VR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> Z SUB STANCE REMAINING .NONE GALLONS INERTMATERIAL7 YES ❑ NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRINTED 6 SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW cf},{' /E'/ <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# F3-Fc) 10161.216 ! z S rf / 11OU <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> l � FOROUW B-N4 <br /> V <br />